Humana Revises Peer-to-Peer Review
By Ellen Terry


 Here’s some news you can use from Humana:


Humana has tweaked its peer-to-peer review process for prior authorization requests, giving physicians contracted with its Medicare Advantage (MA) plans another opportunity for review before filing a claim.

Since Aug. 1, the payer’s MA plans no longer offer peer-to-peer reviews after a medical necessity denial of an authorization request for medical services. Instead, a Humana representative calls the treating physician and offers a peer-to-peer review with a Humana medical director before Humana issues the denial. The physician can submit additional clinical information before the peer-to-peer review.  

However, the Centers for Medicare & Medicaid Services requires Humana to issue an authorization decision within a specified time frame. 

What if you’re unable to hold the peer-to-peer conversation with a Humana medical director before the denial notification goes through? 

If this happens and you are a contracted physician, you now may file a preclaim provider dispute within five calendar days from notification of the denial. (Your patient also may request an appeal.) As part of this dispute, you may request a peer-to-peer conversation if Humana’s adverse determination was based on lack of medical necessity for an authorization request that was retrospective or concurrent to the service. 

Nonparticipating treating physicians’ (or their patients’) only option after a denial decision, with or without peer-to-peer review, is an appeal. 

If you have questions, call Humana at (800) 457-4708.

The Texas Medical Association’s payment specialists continuously review health care payment plans’ newsletters and updates for items important to Texas physicians. Texas Medicine Today periodically publishes key excerpts from those newsletters that you might have missed.

If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit for more resources and information. 

Source: Humana

Last Updated On

October 18, 2018

Originally Published On

October 18, 2018

Related Content

Humana | Insurance

Ellen Terry

Project Manager, Client Services

(512) 370-1391

Ellen Terry has been writing, editing, and managing communication projects at TMA since 2000. She hails from Victoria, Texas; has a journalism degree from Texas State University; and loves to read great fiction. Ellen and her husband have two grown sons and a couple of cats.

More stories by Ellen Terry